Antibiotic Management for Sore Throat Without Fever
Antibiotics should NOT be prescribed for sore throat without fever unless specific clinical criteria are met, as most cases are viral in origin and will resolve without antibiotics. 1, 2
Diagnostic Approach for Sore Throat
- Use the modified Centor criteria to assess likelihood of bacterial infection: fever (by history), tonsillar exudates, tender anterior cervical adenopathy, and absence of cough 1
- Patients with a sore throat and associated symptoms including cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oropharyngeal lesions (ulcers or vesicles) are more likely to have a viral illness and should not receive antibiotics 1, 3
- Patients who meet fewer than 3 Centor criteria do not need to be tested for Group A Streptococcus and should not receive antibiotics 1, 2
When to Consider Antibiotics
- Consider testing for Group A Streptococcus only in patients with 3-4 Centor criteria using rapid antigen detection test and/or throat culture 1, 2
- Antibiotics should only be prescribed for patients with a positive streptococcal test result 1, 4
- Even in confirmed Group A streptococcal infection, the benefit of antibiotics is modest - shortening symptom duration by only 1-2 days 1, 5
Red Flags Requiring Further Evaluation
- Patients with unusually severe signs and symptoms (difficulty swallowing, drooling, neck tenderness or swelling) should be evaluated for rare throat infections such as peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome 1, 2
- Be vigilant for Lemierre syndrome in adolescent and young adult patients with severe pharyngitis, which requires urgent diagnosis and treatment 1, 2
Symptomatic Management (First-Line Approach)
- Offer analgesic therapy to all patients with sore throat, including ibuprofen, acetaminophen, nonsteroidal anti-inflammatory drugs, and throat lozenges 1
- Salt water gargles, viscous lidocaine, and other topical treatments are commonly used in clinical practice for pain relief 1
- Reassure patients that the typical course of a sore throat is less than one week 1, 3
If Antibiotics Are Indicated
- If antibiotics are indicated (positive Group A streptococcal test in a patient with 3-4 Centor criteria), penicillin V is the first choice, given twice or three times daily for 10 days 1, 6
- For patients with penicillin allergy, azithromycin can be used (500 mg on day 1, followed by 250 mg once daily for 4 days) 6, 4
- Be aware that macrolide resistance (including azithromycin) in Group A streptococcus is well-documented and varies geographically 6, 7
Common Pitfalls to Avoid
- Prescribing antibiotics for viral pharyngitis - more than 60% of adults with sore throat receive antibiotics despite most cases being viral 6, 5
- Failing to confirm bacterial etiology before starting antibiotics 6, 3
- Using broad-spectrum antibiotics when narrow-spectrum options would be more appropriate 6, 7
- Treating based on symptoms alone without appropriate testing in patients with moderate to high Centor scores 2, 4